Registered Nurse, Utilization Review

Utilization Review Nurse

The Utilization Review Nurse assists the utilization review process taking on various tasks including data collection of demographic, claim and medical information; analysis; and outcomes reporting. Utilizes standards of care, evidence based practices, Medicare and Medicaid and organizational coverage guidelines to assure members receive high quality, cost efficient health care and services to meet their long term home and community based needs.

Performs utilization review in accordance with all state mandated regulations.

Performance Responsibilities and Standards:

• Assist with the review of member usage patterns for medical necessity and appropriateness.
• Performs continuing review of medical records and supporting documentation for medical necessity where appropriate.
• Tracks and analyzes service utilization patterns monthly and compares to regional benchmarks
• Reviews appeals and provides notice of determination.
• Receives and responds to Office of Temporary and Disability Assistance (OTDA) notifications of Fair Hearings
• Prepares for and attends Fair Hearings.
• Assist with the development of coverage policy guidelines for MLTC services.
• Participates in interdisciplinary collaboration with professional staff.
• Creates and facilitates educational programs.
• Identifies and collaborates with UR Manager on individual cases
• Identifies and collaborates with UR Manager on trends in usage patterns.
• Process Notice of Action letters
• Performs concurrent, prior service authorizations and retrospective reviews
• Analyze per member per month (PMPM) data
• Other duties as assigned

Job Qualifications:

• Current NYS RN licensure, BSN preferred.
• Five or more years of home health care or long term care experience strongly preferred.
• Three or more years of utilization management or quality improvement experience preferred.

Professional competencies, skills and abilities:

• Excellent relationship management skills
• Demonstrated ability to problem solve complex, multifaceted situations
• Successfully manage conflict and negotiate a win win solution
• Strong organizational, prioritizing and delegation skills
• Abstract thinking
• Strong communication skills written and verbal
• Advocacy focused
• Ability to be non-judgmental
• Computer literacy with Microsoft office products

Physical Requirements:

• Speech, visual, and hearing ability sufficient to express and comprehend written and verbal communication
• Ability to sit 90% of the day
• Frequent sitting, standing, walking
• Pushing, pulling, reaching, kneeling
• Bloodborne Pathogens Exposure Determination Category:
  Category III

Compensation & Benefits:

• Competitive Salary with:
• 401K with generous Employer match
• Medical, Dental, Vision plans
• Tuition Reimbursement for BSN after 6 months of employment
• Exceptional work/life balance - no rotating shifts
• Partially funded HSA
• Employee Recognition Platform
• Paid Time Off, Holidays, and Extended Sick Leave
• Short/Long term Disability
• Employee Assistance Program (EAP)
• Much More!!

About Nascentia Health:

Nascentia Health is leading the way in home care, post acute care and long-term community health. A healthcare system without walls, Nascentia is an innovator in the concept of healthcare, truly focused on the patient as a whole. By serving people in their homes, Nascentia Health is able to provide true holistic care. We can address immediate needs, help support positive long term medical and lifestyle choices that provide for better outcomes, leverage cutting edge in-home care technologies, and help avoid unnecessary visits to busy healthcare facilities.

Our employees are our greatest asset. They work hard every day to make our system amazing and are dedicated to our mission of being the premier home and community-based care system for the regions we serve. We want everyone to love what they do, be excited about coming to work, and take pride in being part of our team.

Nascentia Health is an Equal Opportunity Employer (EOE) Employment is contingent upon negative results of a pre-hire drug screen